Are Custom Orthoses Beneficial For Achilles Tendinopathy?

By Brian McCurdy, Managing Editor

Although custom orthoses may be effective for other conditions in the foot and ankle, the authors of a recent study are dubious of their impact for mid-portion Achilles tendinopathy.

Recently published in the British Journal of Sports Medicine, the randomized controlled trial focused on 140 patients with mid-portion Achilles tendinopathy with 67 patients using customized foot orthoses and 73 patients receiving sham foot orthoses. Both groups also performed eccentric calf muscle exercises. Patients completed the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire at baseline, one, three, six and 12 months.

The authors noted no significant differences between the groups at any time point. At three months, the mean VISA-A scores were 82.1 and 79.2 points for the customized and sham foot orthosis groups respectively. The study concluded that customized foot orthoses have no more efficacy than sham foot orthoses to relieve symptoms and improve function in people with mid-portion Achilles tendinopathy participating in an eccentric calf muscle exercise program.

As Patrick DeHeer, DPM, FACFAS, notes, custom orthoses are only a minor component of treatment for Achilles tendinopathy. He says the use of custom devices would be solely based on structural foot pathology in addition to and related to the Achilles tendon pathology (i.e. pronation syndrome).

William DeCarbo, DPM, FACFAS, says his results with custom orthotics for Achilles tendinopathy mirror those in the study as he has not seen a difference in patient function or pain relief. In theory, he notes a pronated foot that puts a lot of strain on the Achilles tendon would benefit from an orthotic but Dr. DeCarbo views the Achilles tendinopathy as a completely separate pathological condition. Although abnormal pronation and Achilles tendinopathy can occur together, he says they are usually independent of each other.

In Dr. DeCarbo’s experience, eccentric calf muscle exercise is the most beneficial treatment for Achilles tendinopathy. He notes equinus is usually the inciting incident or a major contributing factor to this condition. “The bottom line is that equinus is without doubt the primary underlying etiologic factor of most overuse Achilles tendon pathologies,” concurs Dr. DeHeer. “This must be part of any comprehensive treatment plan.”

Strengthening calf muscles can be beneficial to treat Achilles tendinopathy but this is more of an ancillary than a primary therapy, according to Dr. DeHeer, who is in private practice with various offices in Indianapolis.

If eccentric exercises do not resolve the condition, Dr. DeCarbo prefers to use surgical debridement with primary Achilles repair. He excises the degenerated tendon and primarily repairs the remaining portion. Dr. DeHeer would recommend a gastrocnemius recession with or without local surgical intervention. He has also started using amniotic membrane product injections into the area of tendinosis instead of doing an open debridement of the pathological area. With either approach, Dr. DeHeer says the gastrocnemius recession is key to the surgical treatment of equinus.

“I am not sure orthotics can improve the effects of Achilles tendinosis once the degeneration of the tendon has already occurred,” says Dr. DeCarbo, who is in private practice with the Orthopedic Group in Pittsburgh. “Orthotics may play a role in prevention. However, this would be almost impossible to determine.”

Can A New Hindfoot Alignment Angle Help Diagnose Flatfoot?

By Brian McCurdy, Managing Editor

Physicians commonly rely on the hindfoot moment arm to measure hindfoot valgus deformity in patients with stage II adult-acquired flatfoot deformity. However, a recent study in Foot and Ankle International suggests evaluation of a new hindfoot alignment angle to further quantify hindfoot valgus in this patient population.

Study authors reviewed pre-op hindfoot alignment radiographs for 10 feet in patients who were to have reconstruction for stage II flatfoot in comparison with 10 control patients. The study measured the hindfoot moment arm and the new hindfoot alignment angle. Researchers noted that the hindfoot moment arm correlated significantly with the hindfoot alignment angle, increasing by 0.81 mm for every degree increase in angle. They conclude that the new hindfoot alignment angle is reliable and can help differentiate between flatfoot and normal feet.

Neal Blitz, DPM, feels the hindfoot alignment angle in the study has validity because the measurement takes into account the shape of the heel bone on the medial and lateral aspect. He says this may take into account the positional radiographic variations that can throw off other methods that rely on one bony landmark. Dr. Blitz notes that time will tell if surgeons adopt the new angle as it takes extra time to calculate.

When it comes to the hindfoot alignment with flatfoot, Dr. Blitz thinks the radiographic parameters are helpful in quantifying results for research. However, in clinical practice, he says the best measurement of heel alignment is visually looking at the heel valgus to determine its extent and the need for correction.

“Flatfoot surgery is complex and there are several clinical and radiographic measurements that go into determining the surgical course of action, and one single hindfoot measurement angle will not determine how to surgically manage it,” notes Dr. Blitz, a Fellow of the American College of Foot and Ankle Surgeons, who is in private practice in New York City.

Study Says Arthroscopic Debridement Is Effective For Anterior Ankle Impingement

By Brian McCurdy, Managing Editor

Patients who have anterior ankle impingement without osteoarthritis fare well postoperatively after arthroscopic debridement, according to a recent study in the American Journal of Sports Medicine. 

The study examined 46 patients with anterior ankle impingement and no ankle osteoarthritis who had persistent ankle pain and activity restrictions following at least six months of non-operative management. The patients had standardized arthroscopic debridement and a minimum follow-up of five years.

Although patients demonstrated limited improvement in ankle dorsiflexion, going from a mean 24.7 degrees to 27 degrees, researchers noted substantial improvement in the Foot Functional Index from a mean 20.5 to 2.7. However, authors did note that 84 percent of patients had recurrence of radiological osteophytes.

Patients receiving arthroscopic debridement will experience less pain, less infection, less dissection, a lower risk of wound complications and faster recovery, according to Catherine Cheung, DPM. However, she does note disadvantages, including possible neuromuscular damage similar to what one might see with any arthroscopic procedure and possible hemarthrosis. Dr. Cheung does note that surgeons could also experience either complication with an open technique. 

As for surgical technique, Dr. Cheung uses a large burr on the anterior impingement. She cites good results and has not seen any recurrence of radiographic osteophytes.

“(Debridement) probably does take more skill to do arthroscopically and it would be harder to treat large osteophytes as it would take a long time,” says Dr. Cheung, a Fellow of the American College of Foot and Ankle Surgeons, who is in private practice in San Francisco.